The effects of online pilates on the mood and fear of birth of pregnant women: a randomized controlled study

The Pilates exercise method is applied online to various population groups. This study aimed to determine the effect of online Pilates exercises on depression, anxiety, and fear of childbirth in pregnant women. Our randomized controlled study divided participants into the online pilates group (OPG) and the control group (CG). Pilates exercises were applied to the OPG according to the American College of Obstetricians and Gynecologists guidelines, while the CG was given a home program. Assessments were made before and after the training. All measurements improved after Online Pilates (p < 0.05), while there was no change in the control group (p > 0.05). While initial measurement values were similar in both groups (p > 0.05), a statistical difference was observed in favor of OPG with a moderate effect percentage in all results after training (p < 0.05). These results revealed that eight weeks of online Pilates training could effectively reduce depression, anxiety, and fear of childbirth. Trial registration:Clinical trial registry: NCT05305716.


Intervention
Pilates training was conducted online for one hour, two days a week for eight weeks, by Halil Ibrahim Bulguroglu, a certified and experienced Physiotherapist from the Australian Pilates and Physiotherapy Institute, using the Microsoft Teams program.Although there is no international guide for pilates exercises during pregnancy, there are simple recommendations.The Australian Pilates and Physiotherapy Institute has modified the exercises, especially in line with the recommendations of the American College of Obstetricians and Gynecologists 12 .We considered these suggestions in our study.All individuals received one session of training before the Pilates exercise training.In this training, the pregnancy process, what the individual expects during this process, why he/ she should exercise, what Pilates training is, its goals, and why it is an appropriate exercise method for pregnant women were explained, and the key elements of Pilates are; breathing, focusing, rib cage placement, centering, shoulder placement, head and neck placement were taught.During the training, individuals were asked to focus on key elements and maintain the smoothness of these elements during movements.In addition, the Walk-Talk test was explained to pregnant women, and they were told what they should do to ensure that their workload does not exceed moderate intensity.The one-hour program was arranged as a warm-up, pilates exercises, and a cool-down program.The exercise program recommended by the Australian Pilates and Physiotherapy Institute during pregnancy was used in Pilates exercises.We applied online pilates exercises to pregnant women in the same trimester and small groups of 4-5 people.The exercises were explained to the participants using verbal and visual techniques.The pilates exercise program is given in Table 1.Exercises were always applied in the same order.Posture and stretching exercises were applied during the cooling period.Exercise intensity was increased with the resistance of the elastic bands (Theraband et al.Corporation, Akron, Ohio).Resistance was increased by starting with red elastic bands and switching to blue after two weeks.If the new resistance was challenging for the pregnant woman, the exercises were continued with the same color band for another week.During the exercises, participants were informed about side effects such as shortness of breath and dizziness that they may experience and asked to stop exercising if any side effects occurred.After the first evaluation, the pregnant women in the control group were given an approximately 50-min home program consisting of breathing and relaxation exercises.They were asked to practice for one hour twice a week for eight weeks.The first applications were made online under the instructor's supervision, and in the fourth week, they were called by phone to check whether they had completed the program.

Outcome measurements
The participants included in the study were evaluated with data collection forms filled with a questionnaire during a face-to-face interview twice before and after the training programs.The participants' demographic information (age, body weight, height, gestational age, and body mass index) was recorded.Depression symptoms were measured with the Edinburgh Postpartum Depression Scale (EPDS) 27 .Bunevicius et al. 28 reported in their study in 2009 that EPDS is a reliable tool for evaluating depressive symptoms during pregnancy.Other studies also use EPDS in pregnancy 29,30 .EPDS is a self-report scale comprising ten items; the lowest score obtained from the scale is 0, and the highest score is 30.On the scale with a cut-off score of 13, a score of 13 and above indicates the risk of depression.The scale's Cronbach alpha value, which Engindeniz 31 adapted to Turkish and which is valid and reliable, was found to be 0.87.In our study, Cronbach's alpha value was found to be 0.791.Anxiety and Fear of Birth symptoms were secondary outcomes assessed with the State-Trait Anxiety Inventory (STAI Form 1-2) 32 and Wijma Birth Expectation/Experience Questionnaire Version A (W-DEQ-A) 33 .The STAI has two subscales to measure two independent concepts of anxiety: the State Anxiety Scale (S-Anxiety) and the Trait Anxiety Scale (T-Anxiety) are two subscales of the STAI to measure the independent concept of anxiety.State anxiety is defined as the temporary emotional state of an organism, while Trait anxiety is understood as a stable, anxious tendency to increase anxiety.Both subscales have '0 items' , and the four response options range from 0 to 3. A high score indicates a high level of anxiety.Oner and Le Compte 34 made a Turkish adaptation of the questionnaire.Cronbach's alpha values for the Trait Anxiety Scale are between 0.83 and 0.87; for the state anxiety scale, they are between 0.94 and 0.96.In this study, Cronbach's alpha value for the Trait Anxiety Scale was 0.82, and for the State Anxiety Scale was 0.85.The W-DEQ was developed to measure the nature of fear of childbirth by asking women questions about prenatal (version A) and postpartum (version B).Scoring on the 33-item scale is a six-point Likert type numbered from 0 to 5. While the maximum score that can be obtained from the scale is 165, a higher score indicates that women experience more fear of childbirth.The Cronbach alpha value of the scale, adapted to Turkish by Korukcu and Kukulu 35 and has validity and reliability, was found to be 0.89.In our study, Cronbach's alpha value was found to be 0.91.

Statistical analysis
The statistical analysis using SPSS version 21 (SPSS et al., USA) determined the significance level as p < 0.05 in all tests.Normal distribution was determined using histograms, probability plots, and the Shapiro-Wilk test.Median and interquartile range (IQR) were used because descriptive statistics showed an non-normal distribution.The Mann-Whitney U test was used for demographic characteristics, while within-group values at baseline and after eight weeks were compared with the Paired Sample t-test.An Independent sample t-test was used to compare measurement results between the study and control groups.In our study, effect sizes were also evaluated according to Cohen's standards.Effect sizes were interpreted as small (≥ 0.2), medium (≥ 0.5), or large (≥ 0.8) 36 .

Results
One person in the Online Pilates group and two in the control group did not participate in the final evaluation for personal reasons.The study was completed with 26 participants from OPG and 24 from CG among the 58 pregnant women invited within the scope of the study.Figure 1 shows the participants' CONSORT flowchart.No adverse effects were observed in any of our participants during our study.When the post hoc power analysis of the study was calculated, taking depression values into account, the effect size was found to be 1.213.With 26 participants in OPG and 24 participants in CG, the power of the study was calculated as 0.86.
While the demographic characteristics of all participants are shown in Table 2, there was no difference between the groups regarding these variables (p > 0.05).
Although the exercises were performed remotely online, there was an improvement in depression, anxiety, and fear of birth levels in OPG in terms of initial and final values (p < 0.05, Table 3).At the same time, there was no statistical difference in all parameters between the initial and final values in CG (p > 0.05, Table 3).While there was no difference between the initial depression, anxiety, and fear of birth values in both groups (p > 0.05, Table 4), a statistically significant difference was observed with a moderate effect percentage in favor of the Online Pilates group in all parameters in the measurement values after training (p < 0.05, Table 4).

Discussion
This study has shown that online Pilates training in pregnant women may reduce depression, anxiety, and fear of childbirth.Our study found that the depression levels of the participants in the Online Pilates group decreased, while the depression levels in the control group did not change.Although no study in the literature shows the effect of Pilates training on depression levels in pregnant women, studies show that regular exercise reduces depression levels in pregnant women 37,38 .In their meta-analysis study, Davenport et al. 39 stated that exercise was at least as effective as psychological treatments in reducing prenatal depression.However, this effect did not continue in the postpartum period.They also emphasized that pregnant women should do at least 150 min of moderate-intensity exercise weekly for this effect to occur.Ji et al. 40 pointed out the therapeutic effect of exercise in prenatal depression in their meta-analysis.They stated that yoga, gymnastics, aerobic exercise, and resistance exercises have effects on depression in pregnant women, but there is little literature on single exercise methods.It is known from previous studies that regular exercise is effective in stress management, reduces depression, and improves personal self-esteem and body image 39,40 .Pilates training helped participants increase their self-confidence by their awareness through principles such as concentration, breathing, and focus.Increased awareness plays a vital role in reducing the depressive moods of pregnant women.In addition, the fact that pregnant women communicated with other pregnant women through group exercise and thus did not feel lonely was effective in reducing depression levels.In addition, regular exercise may have made pregnant women feel more energetic, strong, and fit 41 and may have reduced their depression.Davenport et al. 39 stated that we arranged their exercises for at least two hours a week and at moderate intensity.As Ji et al. 40 stated in their metaanalysis, we used Pilates exercises, which are aerobic, resistant exercise systems, and parameters such as flexibility and endurance, in our study.We think that Pilates has positive effects on depression, as it is a comprehensive exercise system that has all these characteristics and improves the body in every sense.
In our study, the anxiety levels of pregnant women decreased with Pilates training, but the anxiety level of the control group did not change.Studies have reported high anxiety levels during pregnancy, as was the case at the beginning of our study 30 .Aktan et al. 13 stated that 8-week Pilates and birth training reduced the anxiety levels of pregnant women.In addition, other studies have shown that regular exercise positively affects stress management  and anxiety 41,42 .The results of these studies on anxiety and exercise show similarities with our results.Reducing the level of anxiety will make a significant contribution to the pregnancy processes of pregnant women.The improvement in physical activity level, the physiological benefits of exercise, and its contribution to the mood of pregnant women may have effectively reduced anxiety.Pregnant women's avoidance of both physical activity and social participation also causes a decrease in pregnant women's communication with health professionals 9 .All of these may increase the anxiety levels of pregnant women.However, the fact that participants increase their social participation by exercising in small groups online and having the opportunity to consult a specialist about their problems may have reduced their anxiety levels.
While there was a decrease in the fear of birth of the participants in the Online Pilates group, there was no change in the control group.Sarpkaya Guder 43 , in her study with 108 pregnant, stated that Pilates and childbirth preparation training reduced the fear of childbirth.Pregnant Pilates training includes imagination, relaxation, and breathing techniques that can be done during childbirth.Considering the effects of Pilates training on the musculoskeletal system, all these techniques make the participants more comfortable and prepared for delivery.In addition, the diaphragm exercises used during Pilates can be used primarily in the pushing phase of labor, preparing pregnant women for birth 44 .It may improve the self-confidence of pregnant women, which is necessary for childbirth 14 .All these effects may have helped reduce the fear of childbirth in pregnant women.
Limited studies in the literature examine the effects of pilates exercises during pregnancy.The importance of online exercises is increasing, especially in recent years.Studies on this subject will guide the literature and clinicians.This is the most crucial strength of our study.Another strength is that the exercises are done weekly in small groups, with discipline, and accompanied by a physiotherapist.Our study has certain limitations.Limitations include the fact that pregnant women were not given birth education in addition to exercise, that the sample was not representative, and that pregnant women were not invited face-to-face for an interim check-up.There is a need for studies with larger samples comparing different methods.

Conclusion
Online exercise methods can be used as reliable methods to improve the physical activity levels of pregnant women.This study shows the importance of online Pilates training for pregnant women to gain healthy habits and maintain social participation in all environments.Our study is a study that may guide the literature.Online Pilates training can reduce depression, anxiety, and fear of childbirth in pregnant women.Future studies need to examine the effects of online Pilates training in different groups.In addition, the effects of Online Pilates exercises with different types of online exercises or by adding birth education to the exercises need to be examined.The results of our study present online Pilates exercise training as a safe and applicable exercise method.

Table 2 .
Demographic characteristics of the groups.

Table 3 .
Comparison of depression, anxiety and fear of childbirth levels of groups before and after training.*p < 0.05; 1 : paired samples t-test; X Mean; SD Standard Deviation; OPG Online Pilates group; CG Control group; EPDS Edinburgh Postnatal Depression Scale; WDEQ-A Wijma Delivery Expectancy/Experience Questionnaire A. Significant values are in bold.

Table 4 .
A comparison of the previous and subsequent measurement of depression, anxiety and fear of childbirth for pilates and control groups.*p < 0.05; 2 : Independent simple t test; SD Standart deviation; OPG Online Pilates group; CG Control group.EPDS Edinburgh Postnatal Depression Scale; WDEQ-A Wijma Delivery Expectancy/Experience Questionnaire A. Significant values are in bold.